Learning from changes concurrent with implementing a complex and dynamic intervention to improve urban maternal and perinatal health in Dar es Salaam, Tanzania, 2011-2019

BMJ Global Health, vol. 6, pp. e004022

Abstract

INTRODUCTION: Rapid urbanisation in Dar es Salaam, the main commercial hub in Tanzania, has resulted in congested health facilities, poor quality care, and unacceptably high facility-based maternal and perinatal mortality. Using a participatory approach, the Dar es Salaam regional government in partnership with a non-governmental organisation, Comprehensive Community Based Rehabilitation in Tanzania, implemented a complex, dynamic intervention to improve the quality of care and survival during pregnancy and childbirth. The intervention was rolled out in 22 public health facilities, accounting for 60% of the city's facility births. METHODS: Multiple intervention components addressed gaps across the maternal and perinatal continuum of care (training, infrastructure, routine data quality strengthening and utilisation). Quality of care was measured with the Standards-Based Management and Recognition tool. Temporal trends from 2011 to 2019 in routinely collected, high-quality data on facility utilisation and facility-based maternal and perinatal mortality were analysed. RESULTS: Significant improvements were observed in the 22 health facilities: 41% decongestion in the three most overcrowded hospitals and comparable increase in use of lower level facilities, sixfold increase in quality of care, and overall reductions in facility-based maternal mortality ratio (47%) and stillbirth rate (19%). CONCLUSIONS: This collaborative, multipartner, multilevel real-world implementation, led by the local government, leveraged structures in place to strengthen the urban health system and was sustained through a decade. As depicted in the theory of change, it is highly plausible that this complex intervention with the mediators and confounders contributed to improved distribution of workload, quality of maternity care and survival at birth.

Authors 12

1. Brenda Sequeira Dmello corresponding

   University of Copenhagen · Aga Khan University · Government of Tanzania

   Affiliation as printed

   Global Health Section, Department of Public Health, University of Copenhagen, Kobenhavn, Denmark

   Maternal and Newborn Health, Comprehensive Community Based Rehabilitation in Tanzania, Dar es Salaam, United Republic of Tanzania

   Medical College, Aga Khan University, Dar es Salaam, United Republic of Tanzania

2. Ziada Sellah

   Ministry of Health, Community Development, Gender, Elderly and Children · Government of Tanzania

   Affiliation as printed

   Director, Tanzania Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC), Dodoma, United Republic of Tanzania

3. Grace Magembe

   Ministry of Health, Community Development, Gender, Elderly and Children · Government of Tanzania

   Affiliation as printed

   Director, Tanzania Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC), Dodoma, United Republic of Tanzania

4. Natasha Housseine

   Aga Khan University

   Affiliation as printed

   Medical College, Aga Khan University, Dar es Salaam, United Republic of Tanzania

5. Nanna Maaløe

   University of Copenhagen · Hvidovre Hospital

   Affiliation as printed

   Department of Obstetrics and Gynaecology, Hvidovre Hospital, Hvidovre, Denmark

   Global Health Section, Department of Public Health, University of Copenhagen, Kobenhavn, Denmark

6. Thomas van den Akker Aachen Department of Obstetrics and Gynaecology

   Leiden University Medical Center · Vrije Universiteit Amsterdam

   Affiliation as printed

   Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Noord-Holland, The Netherlands

   Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands

7. Dan Wolf Meyrowitsch

   University of Copenhagen

   Affiliation as printed

   Global Health Section, Department of Public Health, University of Copenhagen, Kobenhavn, Denmark

8. Timothy Mushi

   Government of Tanzania

   Affiliation as printed

   Maternal and Newborn Health, Comprehensive Community Based Rehabilitation in Tanzania, Dar es Salaam, United Republic of Tanzania

9. Mangalu Masweko

   Government of Tanzania

   Affiliation as printed

   Maternal and Newborn Health, Comprehensive Community Based Rehabilitation in Tanzania, Dar es Salaam, United Republic of Tanzania

10. Dorcas Jidayi

    Government of Tanzania

    Affiliation as printed

    Maternal and Newborn Health, Comprehensive Community Based Rehabilitation in Tanzania, Dar es Salaam, United Republic of Tanzania

11. Jos van Roosmalen Aachen Department of Obstetrics and Gynaecology

    Leiden University Medical Center · Vrije Universiteit Amsterdam

    Affiliation as printed

    Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Noord-Holland, The Netherlands

    Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands

12. Hussein L. Kidanto

    Aga Khan University

    Affiliation as printed

    Medical College, Aga Khan University, Dar es Salaam, United Republic of Tanzania